At 38 years old, Amanda Hollis is the new face of lung cancer in America.

Hers began with a cough around Christmas, and didn’t seem like a big deal. Everyone around her was germ-ridden: Her kids, who were bringing home colds and flu like they do every winter. Her co-workers were coughing and sneezing, too. But by spring, Hollis was still coughing, sneezing, and starting to wheeze. “I just didn’t think about it,” says Hollis, a web developer and communications specialist, who lives in northern New Jersey with her husband and three young children.

By Memorial Day weekend, Hollis couldn’t catch her breath. “It was as if someone or something just knocked all the air out of me. I was standing at the sink in the kitchen gasping like a fish out of water—taking big gulps of air and feeling like I couldn’t breathe.”

Hollis says she cried out for her husband right before she passed out. She woke up in the ambulance taking her to the hospital, her husband and two EMTs crammed in with her, an oxygen mask over her face and her heart beating wildly in her chest. She tried to ask about the couple’s children, but found she didn’t have enough air to speak.

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Within 36 hours, Hollis and her husband were given the grim news as she lay in her hospital bed in the intensive care unit—she had adenocarcinoma—a common form of lung cancer in women. A series of emergency tests, including lung X-rays, CAT and PET scans had determined that Hollis was lucky—she had stage I leaning to stage II cancer, which meant treatment options were good and life expectancy longer than most.

Twice as many women die of lung cancer each year as die of breast cancer, yet lung-cancer awareness is as hidden as the statistics for the disease itself.

In the U.S., every seven minutes a woman dies of lung cancer. One hundred and ninety-eight women will die of lung cancer today. And tomorrow, and the next day, and the next, until that number goes up, as it has every year since 1995. Yet, few Americans even know these statistics. Lung cancer represents 25 percent of all cancer deaths in women each year, making it the leading cause of cancer death among women (and men). Twice as many women die of lung cancer each year as die of breast cancer, yet there are no special campaigns, no cities lit up for a month of awareness, no campaign promotions, no products devoting percentages sold to research, no annual runs across America with women wearing T-shirts emblazoned with a race for the lung-cancer cure as there are for breast cancer with that sea-of-pink everything. Lung-cancer awareness is as hidden as the statistics for the disease itself.

Yet women keep dying, and now they are dying younger.

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New research published in Very Well Health in April indicates that “between 2 and 6 percent of women diagnosed with lung cancer are under the age of 40, and 13.4 percent are under the age of 50,” writes Dr. Lynne Eldridge, an expert in lung cancer diagnosis, care, and treatment. A graduate of Stanford and the University of Minnesota Medical School, Eldridge has been treating patients in St. Paul and traveling nationally to speak about lung cancer for nearly two decades and has received the Global Lung Cancer Coalition Excellence in Journalism Award for her writing on lung cancer. Eldridge explains the data, “A quick calculation reveals that roughly 30,000 people under the age of 50 will be diagnosed with lung cancer in 2017 and slightly over 21,000 young adults will die from the disease.”

To put that statistic into perspective, Eldridge says “an estimated 40,000 women will die of breast cancer this year, about 20 percent of whom will be under the age of 54,” adding that “8,300 women under the age of 54 will die from breast cancer. It’s likely that many people would be surprised by these numbers.”

Nearly three times the number of young women will die from lung cancer as will die from breast cancer. It’s a stunning statistic.

Cancer has long been a disease that predominantly affects people over 50. Yet this is changing rapidly among women, particularly those with lung cancer. Young women with lung cancer have higher rates of survival than men. With Hollis’s diagnosis, her survival rate past five years is close to 70 percent. A June study published in the New England Journal of Medicine shows that the long-established trend in the U.S. for lung cancer—that more men get the disease than women—has shifted. The collaborative study between the American Cancer Society and the National Cancer Institute found that Gen X and millennial women are now more likely to get the disease than their male peers.

No one knows why. And no one is looking for lung cancer in young women. Eldridge found, “a greater number of young patients are diagnosed with stage-4 disease. Lung cancer, especially in young, healthy never-smokers, isn’t usually high on a doctor’s radar, and this can result in a delay in diagnosis. Those who are young are often first diagnosed with asthma, bronchitis, or even allergies before the [cancer] diagnosis is finally made. Many young people have had chest X-rays, which have failed to show the cancer.”

While the NEJM report of the ACS/NCI study reveals that lung cancer is affecting more women, it’s not clear about the reasons why. Smoking remains the leading cause of lung cancer (and a contributing factor in other cancers as well). Fewer people are smoking cigarettes than in 1995, the first year of the study. However, vaping and e-cigarettes are increasingly popular among younger smokers.

At the National Meeting & Exposition of the American Chemical Society (ACS) in August 2018, ACS, the world’s largest scientific society, profiled a study by the University of Minnesota Masonic Cancer Center released in August 2018.That study, the latest and most comprehensive on the impact of vaping, showed that four out of five vapers experienced DNA changes that could lead to cancer. However, the ACS/NCI study also revealed that the number of lung cancer deaths were highest in 2014, the last year covered by that ACS/NCI study. An increasing number of women who’ve never smoked are being diagnosed with lung cancer. In fact, the increase in lung cancer among never-smokers is its own cancer trend. If put into its own category, lung cancer among those who don’t smoke would rank as the sixth most fatal cancer in the U.S. Among non-smokers, lung cancers tend to occur at younger ages and be more advanced.

In October, the Lung Cancer Alliance reported that lung cancer is on the rise among non-smoking women—but not in non-smoking men. In fact, two-thirds of non-smoking lung cancers are women, and more than 20 percent of women diagnosed with lung cancer have never smoked. This percentage is significantly higher among Asian women. Though there are no definitive reasons why, there are indicators that it is environmental and may impact women more aggressively than men, in part because women’s lungs are smaller. According to the National Institutes of Health, lung cancer presents quite differently in women than in men, women get lung cancer at a younger age and more research must be done to expand data for treatment and clinical trials.

Hollis smoked in college and graduate school, but was never a heavy smoker. “I was a stress smoker,” she says. “I never smoked more than a pack a week and I pretty much stopped smoking the day of graduation. Smoking seemed to be directly linked to college for me.” She said she and her husband, always a non-smoker, never allowed smoking in their home because of their children. “I just don’t see how the short time I was smoking could have given me cancer,” she said.

But just one to four cigarettes per day can raise a woman’s risk of lung cancer, as well as heart disease and stroke, according to a January 2018 study in the British Medical Journal. And once a woman is diagnosed, the prognosis is not good. The five-year survival rate for lung cancer is 56 percent for cases detected when the disease is still localized (within the lungs), but only 16 percent of cases are diagnosed at an early stage, due to lack of awareness about symptoms and less research into how to detect the disease earlier. In metastatic lung cancer that has spread to other organs, like the liver, bones and brain, the five-year survival rate is only 5 percent. These numbers are vastly different from those for breast cancer, which is now considered one of the most curable cancers, with nearly 100 percent survival rates after five years in most non-metastatic forms of the disease, with treatment.

Public awareness as well as perceptions of the disease play a big role in research, funding, and likely survival rates. In 2016, breast cancer research received $572.6 million from the National Cancer Institute in 2016—the most for any cancer. Comparatively, in 2016, lung cancer research garnered less than half that: $247.6 million. And breast cancer had yet more avenues for research funding. An additional $705 million was allocated by the National Institutes of Health for breast cancer. The Susan G. Komen Foundation—via those pink-shirted Race for the Cure events each year on Mother’s Day—raised an additional $162 million. The stigma attached to lung cancer—that people “caused” their cancer by smoking—is thought to have stymied fund-raising for research, according to the National Institutes of Health.

If more money was spent on lung cancer awareness and education campaigns; if its white ribbon were as prominent as breast cancer’s pink one; if the focus was less about shaming people for smoking—be it one cigarette a week, or a pack a day—and more about educating everyone on one of the most fatal cancers for women, we might be able to detect it earlier, treat it, and save lives.

Cancer survival is largely dependent on detection and treatment. Many women know the warning signs of breast cancer—we have been told about breast self-exams for years and told to be aware of any changes in our breasts. But do women know the warning signs of lung cancer? Because many of us are often unaware of the threat posed by lung cancer, studies show we tend to ignore symptoms, as Hollis did. Women who don’t smoke don’t even consider lung cancer as a possible diagnosis.

When singer Dana Reeve lost her husband, actor Christopher, in 2004, she used her celebrity to draw attention to the disease. She revealed her lung cancer diagnosis a mere six months after his death. She had never smoked, and postulated that her years as a chanteuse in clubs had exposed her to second-hand smoke, a leading cause of cancer. She died two years later at age 44.

According to the U.S. Surgeon General, between 1964, when the link between smoking and cancer began to be tracked, and 2014, the last year studied, exposure to second-hand smoke caused 2.5 million deaths from lung cancer. If that number seems huge, it is. The impact of second-hand smoke on non-smokers can be deadly. The Centers for Disease Control cites second-hand smoke as a cause of lung cancer, asthma and even Sudden Infant Death Syndrome (SIDS), also known as crib death in infants. In 2014, the CDC added stroke to the list of illnesses attributable to second-hand smoke exposure.

What has yet to be studied fully, because it is a relatively new smoking trend, is the impact of vaping/e-cigarettes on lung cancer rates among women, men or teens. The CDC reports that teens are vaping more often than they are smoking cigarettes, with 20 percent of high school students using at least one tobacco product recently—mostly e-cigarettes. In 2016, 11 percent of high-school students had recently used an e-cigarette. The study found that teens were most attracted to the fruit-flavored vapes, but that these had the most harmful chemicals and were most addictive.

On November 5, CNN reported that Juul had been trying to get their own anti-smoking program into the schools. Juul, which has replaced other cumbersome vape products with a tiny pod half the size of a tobacco cigarette, is also far more powerful. According to the CNN report, one Juul pod has as much nicotine as 20 cigarettes—an entire pack. It’s smoking, just a different delivery system, and one unabashedly targeting youth with its high coolness factor. Matthew Myers, president of the Campaign for Tobacco-Free Kids, was interviewed in the CNN report. Myers said Juul may not even have been in the CDC’s survey.

“Juul was not specifically mentioned in the survey, and many teens refer to Juul use as ‘juuling,’ indicating they may not consider it to be using an e-cigarette,” Myers said. “Juul looks like a USB flash drive and is easy to hide, comes in sweet flavors like mango and fruit medley, and delivers a powerful dose of nicotine, putting kids at greater risk of addiction.”

FDA Commissioner Dr. Scott Gottlieb issued a statement on November 15 proposing new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes. Gottlieb, a cancer survivor and the father of three young children, declared in a long, personal and deeply heartfelt statement that “when I pledged last year to reduce addiction to nicotine, I was driven by the fact that, in the U.S., tobacco use remains the leading cause of preventable death and disease.”

In an editorial on November 17, the Washington Post Editorial Board declared the FDA directive “a victory for public health,” writing, “These measures come in response to a shocking spike in youth e-cigarette use, up 78 percent among high schoolers since last year.” The Post cites Juul as “the main culprit,” explaining that Juul’s size and the disappearing vapor of the system make it virtually undetectable to parents and other adults. The editorial also cites the tobacco industry’s targeting of Black Americans with menthol cigarettes, who use menthol more than other groups and notes “the FDA should have taken this step eight years ago. It is past time to start the regulatory ball rolling.”

The confluence of all these studies from the CDC and various medical journals leads to the same conclusion: Women are getting lung cancer, they are getting it younger, it is killing them more and faster and now teenagers are getting lured into smoking sexy, hip Juul pods that may be just as deadly as tobacco cigarettes and could result in another wave of cancers in a decade or so, after the impact of vaping is fully known and studied.

The dearth of research on lung cancer means little is known about the reasons why some young women like Hollis, who hadn’t smoked in over a decade and who never smoked heavily, get lung cancer. What is known for certain is that knowing the risks and the warning signs are vital and must become as common for women as that breast self-exam, because 198 women dying each day from lung cancer is a statistic too few of us will know until it is too late.

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About the Author

Victoria A. Brownworth is an award-winning investigative reporter and columnist. Her work has appeared in numerous American and international publications, including the Philadelphia Inquirer, Philadelphia Daily News, Baltimore Sun, the Independent, New York Times, the Nation, Slate, Curve, HuffPost and SPIN. She's the author and editor of more than 20 books, including the award-winning Coming Out of Cancer, Restricted Access, Too Queer: Essays from a Radical Life, From Where We Sit: Black Writers Write Black Youth, and Ordinary Mayhem.